PERSONAL ACCIDENT CLAIM FORM

Transcription

1 PERSONAL ACCIDENT CLAIM FORM Please complete this form ( including Access to Medical Records & Reports form ) in BLOCK CAPITALS and return it to Rightpath Claims as soon as possible with the following original documents: Proof of insurance Medical Reports Incident Reports ( e.g. Police report ) Booking invoice ( if on trip) Benefits paid weekly/monthly must be supported by wage slips for the 12 months immediately prior to the incident. IMPORTANT: Documents will be destroyed after 6 months of receipt. CLAIM NO: Z Insured Person s Details Title: First name: Surname: Date of birth: Daytime telephone number: address: Contact s Details (if different) Title: First name: Surname: Date of birth: Daytime telephone number: address: Insurance Details Complete A and ignore B if your cover is provided as part of a travel insurance policy. Complete B and ignore A if your cover is provided under a personal accident policy. A. Travel Insurance Policy Travel insurance policy number/reference ( including prefix ) : Which company did you purchase your travel insurance from? Date insurance purchased: B. Group Policy Policy number/ reference ( i ncluding prefix ) : Group/Company/Association name: Contact at Group/Company/Association name: Date insurance purchased:

2 Incident Details Country of incident: Town /resort: If the incident occurred on a trip please complete the following, otherwise skip to C ircumstance : Date journey booked: Departure Date: Return Date: Trip duration: days Name of Tour Operator ( if applicable ) : Name of Travel Agent ( if applicable ) : Circumstances : Date: Time: Place of incident: Is a Police / accident report available? Please provide full circumstances of the incident giving rise to this claim: Please confirm the nature of your claim: Death Loss of Sight If Other, please specify: Loss of Limb Permanent Total Disablement Temporary Total Disablement Other Have you ever suffered from this or any related disability, prior to the start of the insurance? If YES, please provide full details: Date from which you have been unable to attend your normal occupation: Are you still incapacitated as a result of your Accident/Illness? If NO, please provide the date of your return to: Parts of your duties: All of your duties:

3 Circumstances - continued What is your expected date of return to work? Have you previously claimed benefits under this insurance? If YES, please provide details: Please provide the full name and address of your employer at the commencement of disability: Medical Practitioner Details Please provide the full name and address of your usual General Practitioner: Please provide the full name and address of the attending Doctor if different from above: Payment Details If we can pay your claim, we will transfer payment directly to your bank account. Please confirm: Account No: Sort Code: - - Declaration I/ We declare that the above statements are accurate and correct to the best of my/ our knowledge. I/ We agree to provide the insurer with any further information which may reasonably be required. I/ We understand that by sending this form, the insurer does not accept liability. I/ We assign all rights of recovery/ salvage to the insurer and will do whatever is necessary to assign such rights. I/We understand that some of the information provided will be made available to other insurers for underwriting and claims handling purposes. I/ We understand that the making of a fraudulent or exaggerated claim is a criminal offence and will leave us liable to prosecution. Signed: Print name: Date:

4 ACCESS TO MEDICAL RECORDS FORM Your consent is needed before we can apply for a medical report from your doctor, or other medical practitioner. This is governed by the Access to Medical Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991 (made under the Northern Ireland Act 1974) and the Data Protection Act In the event that you do not consent, we may be unable to process your claim, or continue with benefits for a claim already in existence. If you do consent then you have a choice whether or not to see the report before your doctor, or other medical practitioner, forwards it to us. If you indicate below that you wish to see the report, you will have twenty-one (21) days after you have received our notification in which to contact your doctor, or other medical practitioner. If you indicate that you do not wish to see the Report but later change your mind, you are entitled to request a copy directly form your doctor, or other medical practitioner, for up to six (6) months after it has been sent to us. If you are supplied with a copy of the Report your doctor, or other medical practitioner, is entitled to charge you a reasonable fee to cover costs. In addition, if your doctor, or other medical practitioner, spends time with you discussing your Report there is an additional entitlement to charge a fee to cover the time involved as this would not fall within the NHS Terms of Service. Your doctor is not obliged to let you see any part of the report if it is felt that it would cause you harm, would indicate his intentions towards you or would reveal the identity or details of another person who is not a professional involved in your care. Your doctor, or other medical practitioner, will inform you if this applies to sections of your Report and you may see the remaining parts, If the whole Report is affected then it will not be forwarded to us without your written consent. You are entitled to write to your doctor, or other medical practitioner, and request that your Report be amended if you consider it, or any part of it, to be incorrect or misleading. If your doctor, or other medical practitioner, is not prepared to amend your Report, a statement of your views can be attached to it. Please tick the appropriate box, complete the form below and return it to us. I do not wish to see the Report before it is sent. I wish to see the Report before it is sent. Your Medical Practitioners Details Address Postcode Data Protection Act 1988 Rightpath Claims will fairly and lawfully collect and record personal information that is supplied within and as a result of this form. We shall share information with your underwriters and their agents and, in certain cases, with other underwriters to help detect and prevent fraudulent claims. We require your consent to process information in this way and by completing and signing this form you are explicitly providing that consent. Your details Your name: Your address: Postcode Signed: Date:

5 MEDICAL CERTIFICATE Personal Accident Z This form must be completed by the GP or attending specialist of the person whose medical condition gives rise to this claim. Any fee for completing this form is the responsibility of the patient/ claimant. To avoid delay and unnecessary correspondence, please complete this certificate in BLOCK CAPITALS, answering each question as fully as possible. The form must be returned to: Rightpath Claims, Airport House, Purley Way, Croydon, Surrey, CR0 0XZ Telephone: This form must be filled-in with relation to: (Please ensure this is completed before referral to the GP or attending specialist) Name of Patient: Date of Birth: Medical Certificate: ( To be completed by the GP or attending specialist ) Q1. Are you the usual Medical Attendant of the Patient: Q2. If YES, how long have you been the Patient s GP/specialist? Q3. What date did the Patient first suffer symptoms for his/her present disability? years months Q4. Please confirm the nature of illness / injury sustained and advise on the precise diagnosis, causation and treatment prescribed: Q5. Has the Patient suffered from this or any other associated medical condition prior to this period of disability? Q6. If the answer to Q5 is YES, please provide the dates of the diagnosis and treatments prescribed: Q7. At the time of the accident or commencement of illness was the claimant suffering from any other illness, sickness, degenerative condition or disease? Q8. If the answer to Q7 is YES, please state the diagnosis, the date diagnosed, all treatments prescribed and advise whether this will hinder, delay or impede recovery of the claimed disability / diagnosis?

6 Medical Certificate - continued Q9. Is the disability due to self inflicted injury, consumption of alcohol, drug abuse, childbirth, pregnancy, abortion or venereal disease or other sexually transmitted disease or HIV related illness including Acquired Immune Deficiency Syndrome ( A.I.D.S ) or A.I.D.S Related Complex ( A.R.C )? Q10. If the answer to Q9 is YES, please provide details: Q11. Is the Patient presently confined to their home? Q12. Has the Patient been confined to their home since commencement of disability? Q13. On what date did you first sign the Patient as unfit for work? Q14. When do you expect the Patient to return to work? Part of their duties: All of their duties: Q15. Do you certify that the Patients absence has occurred solely due to the medical diagnosis claimed? Q16. If the Patient has already returned to work, please state the date and whether he/she was able to return to all, or just part of his / her duties: Doctor Declaration I certify that the information provided in this Medical Certificate is true and accurate to the best of my knowledge and belief. Name of GP: Official Practice Stamp: Signature: Contact number: Qualifications: Date:

7 CHECK LIST PERSONAL ACCIDENT KEEP THIS PART OF THE FORM FOR YOUR RECORDS This part of the claims form may be kept by you. Use this CHECK LIST to help ensure you send us everything we need to conclude your claim on first review. Failure to provide us with all the relevant information and documentation will create delays. Whilst this form covers the main documents we may require further documents not listed. To make the process more efficient - please send us the information/documentation all together. CLAIM FORM Have you answered all of the questions? Often questions that you may consider not applicable actually are - the reasons aren t always that obvious. Please ensure you enter your claim reference on the front of the Claims Form and Medical Certificate. Please ensure you have completed the ACCESS TO MEDICAL RECORDS FORM. MEDICAL CERTIFICATE Please make sure the medical certificate is completed in full by your GP or attending specialist and has been stamped. Please make sure all the questions have been completed by them and you are in agreement with what your doctor has put and resolved any queries with them before you send us the form. PROOF OF INSURANCE We are independent claims handlers appointed by insurers to handle claims on their behalf. We do not always have direct access to your policy data. This is why we ask for a copy of your proof of insurance. If you have an annual multi-trip policy you can send us a copy. BOOKING INVOICE / PROOF OF TRAVEL DATES ( IF APPLICABLE ) These documents confirm the date the trip was booked and we can accept, booking invoices/ s. If you have not retained any of these documents whoever you booked through should be able to provide a duplicate copy of your booking invoice. INCIDENT REPORTS If applicable, please provide any incident reports (e.g. police report) that are available that support the circumstances of your claim. PROOF OF SALARY FOR 12 MONTHS BEFORE INCIDENT If you are claiming for a benefit that is payable as a weekly or monthly amount, please provide proof of salary for the 12 months that immediately preceding the incident. If you do not have your original payslips we suggest liaising with your HR / Payroll department. If you are self-employed please provide your tax returns/audited accounts. COPIES TAKEN For safe-keeping we always recommend you take copies of your documents before sending them to us. Useful Information Date I sent the claims form to Rightpath: My Claim Number: If you are sending the claim form by post please allow up to 9 days for our response: 2 days for delivery, up to 7 days (5 working days) for the assessment and 2 days for a posted response. Rightpath Claims contact details: Rightpath Claims, PO Box 6053, ROCHFORD, SS1 9TT, UK Phone: / + 44 (0) admin@rpclaims.com Z You can also check the status of your claim online by visiting: